What is the role of research in medicine? While it is impossible to quantify, it is important to analyze if we are to continue expending countless hours and money into the medical sciences. Some have argued that the two should not and cannot mix in the first place. Paul De Kruif spends chapters in Our Medicine Men trying prove that the entities of science and that of medicine should be left separate, and that the two should not flirt with each other: “It is certain that this pretense of physicians threatens to turn medicine from its primordial and proper function of healing and soothing our ills, toward a quackish assumption of the dignity of science. It is possible to study disease scientifically, but it is absurd to presume that this can be done by the rank and file of doctors” [1]. Others have questioned this same notion: “Would not investigations, pursued perhaps out of sheer curiosity, distract a man from his first duty to patients?” [2]. Nobel laureate Macfalane Burnet also makes some pretty provocative statements about the medical sciences: “The real problem of today is to find some means of diminishing the incidence of these diseases [cancer and genetic disabilities] of civilization … it remains, the most urgent and difficult challenge in medicine. Nothing from the laboratories seems to have any relevance to such matters.” He goes on to say that “almost none of the modern basic research in the medical sciences has any direct or indirect bearing on the prevention of disease or on the improvement of the medical care.” [3] Most of these writers have been heavily criticized for such bold assertions, and you would be hard pressed to find physicians and scientists today that agree with them. However, they pose some interesting questions that need to be answered to establish a niche for research in medicine. Can the characteristics of scientist and physician work together efficiently? And do the products of their investigations into science have influence on the medical side of the equation? As we will see, medical practice and scientific investigation can coexist effectively and can have impact on the fight against disease and improvement of medical care. In addition, medical research serves to bolster the profession, as advancement in medical practice cannot happen without scientific investigation.
Theobald Smith is an example of an investigator that disproves the naysayers of the relationship between bench work and clinical impact. Graduating from Albany Medical College in 1884, his medical underlying proved to be very beneficial in his investigations into the “Texas Fever” that plagued, not humans, but cows. A very puzzling affliction burdened southern stock raisers of the time. Whenever southern cows were brought into contact with northern cows, after sometime, the northern counterparts would fall extremely ill and eventually die. This happened whether northern cows were placed in the southern environments or if the southern cows were brought in proximity of the northern cows, the northern cows just didn’t stand a chance. Dr. Smith was put on the task to solve this puzzle. An idea that was scoffed at during the time, these cattlemen thought that ticks were the root of the problem. This idea that insects can bring on disease was considered an absurdity at the time; however, Smith thought otherwise and set out to test this hypothesis. Using sound experimental technique, he created different experimental groups by placing different cows in separate fields and introducing the ticks in various ways, such as introducing northern cows to southern ones and viewing tick dispersion, doing the same and removing the ticks (one by one by hand!) from the southern cows, and various other experimental models. He was even able to culture these ticks and use them wherever he saw fit. As a by-product, these experiments brought much insight into how ticks live and thrive off their host, but the important conclusion of these experiments was that the ticks cause the disease. Further insight was also shed into the idea of immunity; as southern cows were generally not affected by the disease. Now that the link between parasite and disease was made, the full impact of his work could easily be seen; the cause of diseases such as malaria, yellow fever, Lyme disease, could all be easily be deciphered and pinpointed. The result of Dr. Smith’s work brought huge impact to clinical practice and medical sciences (in humans as well as other animals) in this regard. Sound experimental investigation brought immediate impact to the medical profession, thereby further disproving previous thought that this simply does not happen in reality. It is truly innovative ideas in science that perpetuate the medical profession. [4]
As Theobald Smith could be viewed as predominantly a scientist, the other question still remains: Can research and medical practice coexist effectively in medical institutions and practitioners? The prominent physician Lewis Thomas had an interesting take on this question: “Self confidence is by general consent one of the essentials to the practice of medicine for it breeds confidence, faith, and hope. Diffidence, by equally general consent, is an essential quality of investigation. Here then are chief characteristics, each necessary in its own sphere, each unsuited to the other…” [5] Dr. Judah Folkman is the epitome of physician scientist and he proves that both self confidence and diffidence can exist together, each one supporting the other. A fine surgeon by most standards, he was chief of surgery of Children’s Hospital Boston for fourteen years. All the while, he was in hot pursuit of his radically new idea (at the time) of angiogenesis, and was convinced he could use it to target cancer. There were still many that questioned his devotion to surgery and to his patients even some that thought that he was wasting his time and talent messing around in the laboratory. As Robert Cooke proves in his biography on Dr. Folkman, Dr. Folkman’s War, it was this application of science that improved his ability to serve his patients, to constantly question and solve problems that arose at both levels. [6] Although his character and dedication far surpasses that of average doctors and scientists, he proves that the he could impact both medical practice and scientific knowledge.
However, can research benefit the medical profession as a whole? For one thing, it improves the way medicine is taught and understood by its students. Medical education is the foundation and stepping stone of the institution of medicine. With collaborative learning into the practicalities of medicine along with investigations into the basic sciences, the student is better suited to practice this medicine. Abraham Flexner puts it best in his book, Medical Education in the United States and Canada, when he says “modern medicine … is characterized by activity. The student no longer merely watches, listens, memorizes; he does. His own activities in the laboratory and in the clinic are the main factors in his instruction and discipline. An education in medicine nowadays involves both learning and learning how.” [7] He goes on to describe the scientific method as not only a tool for the investigator, but also for the physician working at the bedside. This process is highly hypothesis driven and highly evaluative of facts and problems, allowing students to be analytical, thorough, and critically open minded. These qualities are not only important for the student, but also the teacher of medicine. Not only to keep the faculty “conditioned” as Flexner describes, but also to keep the establishment of teaching up to par, as a “non-productive school, conceivably up to date today, would be out of date tomorrow; its dead atmosphere would soon breed a careless and unenlightened dogmatism.” [7] Medical research serves to keep the quality of medical education high, at both the teacher and student ends.
History is not pardoned from this dichotomy of medical practice and science. From the earliest of civilizations, the practice of medicine could easily be described as an art form; the practitioners of this medicine relied heavily on observation and empiricism. Even today, much medical practice it appears is still based around these empirical approaches. The physician David Weatherall, in book Science and the Quiet Art: The Role of Medical Research in Health Care, uses the example of appendicitis, in that there is still no definitive test for this condition. Much is dependent on the physicians’ diagnostic skills, observations, and previous insight, and even there are instances where the abdomen is opened to find no problem at all. [5] It is these observations at the bedside, however, that are the stepping point for investigation at the bench. Many argue that we have yet to see prominent results at the bedside, for many of our prominent diseases, from the many years and countless dollars spent on biomedical research. Much of this has to do with the portrayal of the biomedical sciences by the media, with its constant barrage of “breakthroughs” everyday with little benefit to the patient, and knee jerk reactions and impatience on the part of the public. It is these advancements made in the past that keep us constantly riddled with even more problems to solve. There is this constancy of investigation. Taking a historical perspective of the medical sciences, it could be seen that centuries of work has been amassed to produce our current understanding of the human body and disease, from Hippocrates to Galen, William Harvey to Pasteur, Mendel and Darwin. The list is endless but the pattern is the same: each built upon previous work and questions and produced valuable knowledge which constitutes our current understanding. Looking at the previous century, we almost dominated infectious diseases (looking specifically at Western countries), but diseases like small pox and rubella have now been replaced with cancer, cardiovascular diseases, and mental illness. The discovery of insulin has produced vast insight into our nutritional system and diseases such as diabetes, but since its discovery, many of the questions of these diseases still exist. Taking aside the sad reality of this perpetual cycle, it is to medical science and research that we owe these advances in understanding, moving from the empirical and observational to the scientific. It is in our best interest to continue this research to keep the foundations of heath care sound.
It is important, however, to divulge the limitations of the medical sciences in the quest to eradicate disease. Thomas McKeown, in his book The Role of Medicine, makes the argument that the decline of infectious diseases in the past century was not due to advancements in the sciences but improvement in hygiene, nutrition, social conditions, and other environmental factors. [8] While we must accredit improvements on infectious disease control to these factors, it is impossible to see if the decline in mortality from these diseases would have continued without scientific advancements such as antibiotics and immunization. Taking this aside, however, McKeown also points to the importance of understanding the origins of disease in its control. Epidemiological studies have been critical in correlating factors that cause cancer, such as the use of cigarettes, or links to diets and exercise in cardiovascular diseases. In its most famous example, John Snow was able to control cholera in the SoHo district in London not by mechanistic studies of the disease, but through epidemiological evidence. [9] These studies, while greatly increasing our knowledge base of disease, are not without their limitations as well. There is only so much we could learn by analyzing environmental agents and lifestyles in disease without introducing error with the insurmountable number of variables in these types of studies. They do have important implications in preventative medicine, and we could make great strides in public health through their analysis. It is the combination of studies like these, along with clinical and basic science research, that will continue to shape the application of medical science.
Medicine will always remain an “art,” but with medical research and investigation, we can come closer to moving the practice of medicine away from empiricism to scientific discipline. Prominent examples of physician-scientists like Theobald Smith or Dr. Folkman have proved that self confidence and diffidence can exist together in the application of medicine. Science has had vast impact on the practice of medicine. Its role is multifaceted, as it not only supports medical practice but its education as well. It is not without its limitations, and we must analyze it on all levels, from the origins of disease, to its mechanisms, to investigations to improve health care as a whole. We must also learn to serve patients better, because that is the point of it all. As a race, we have made much progress in our understanding of the complexities of life, at many levels, but patience is necessary. We cannot expect to solve all the problems at once, as more questions will arise. The complexities of the diseases that we face make it hard to produce a magic bullet that cures all. But more knowledge will allow us to target these diseases better, reduce premature deaths, and improve the quality of life. As this knowledge increases, more ethical issues will arise, and it is the responsibility of all to be well informed in the end goal of improving health. Lewis Thomas put it eloquently in the final paragraph of his book, The Medusa and the Snail: “We need to know more … We have discovered how to ask important questions, and now we really do need, as an urgent matter, for the sake of our civilization, to obtain some answers. We now know that we cannot do this any longer by searching our minds, for there is not enough there to search, nor can we find the truth by guessing at it or by making up stories for ourselves. We cannot stop where we are, stuck with today’s level of understanding, nor can we go back … We need science, more and better science, not for its technology, not for leisure, not even for health or longevity, but for the hope of wisdom which our kind of culture must acquire for its survival.” [10]
1. Kruif P. The Dignity of the Medical Profession. Our Medicine Men. New York: The Century Co.; 1922. p. 3-18.
2. Shryock RH. Medical Thought and Practice. Medicine and Society in America: 1660-1860. Ithaca: Cornell University Press; 1960. p. 44-82.
3. Burnet SM. The New Outlook. Genes, Dreams, and Realities. New York: Basic Books, Inc.; 1971. p. 217-27.
4. Kruif P. Theobald Smith: Ticks and Texas Fever. Microbe Hunters. Cornwall: Harcourt, Brace and Company, Inc.; 1926. p. 234-52.
5. Weatherall D. Science and the Quiet Art: The Role of Medical Research in Health Care. First ed. New York: W. W. Norton & Company; 1995
6. Cooke R. Dr. Folkman’s War: Angiogenesis and the Struggle to Defeat Cancer. New York: Random House; 2001.
7. Flexner A. The Course of Study: The Laboratory Branches. First and Second Years. Medical Education in the United States: A Report to the Carnegie Foundation for the Advancement of Teaching. Boston: The Merrymount Press; 1910. p. 53-71.
8. McKeown T. Medical Research. The Role of Medicine. Princeton: Princeton University Press; 1979. p. 156-75.
9. Johnson S. The Ghost Map: The Story of London’s Most Terrifying Epidemic — and How It Changed Science, Cities, and the Modern World. New York: Riverhead Books; 2006.
10. Thomas L. Medical Lessons from History. The Medusa and the Snail. New York: The Viking Press; 1979. p. 158-75.
Contributing Writer Emeritus
Albany Medical College
Ankit Modh is a Class of 2014 medical student from Long Island, New York. He received his bachelor's in biology from Rensselaer Polytechnic Institute. He is currently on a year-out pursuing his interests including research and writing.
